Healthcare Provider Details

I. General information

NPI: 1902876337
Provider Name (Legal Business Name): SUTTER LAKESIDE HOME MEDICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 01/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

843 PARALLEL DR
LAKEPORT CA
95453-5707
US

IV. Provider business mailing address

843 PARALLEL DR
LAKEPORT CA
95453-5707
US

V. Phone/Fax

Practice location:
  • Phone: 707-263-7400
  • Fax: 707-263-1964
Mailing address:
  • Phone: 707-263-7400
  • Fax: 707-263-1964

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number010000118
License Number StateCA

VIII. Authorized Official

Name: MS. FAITH D LYKKEN
Title or Position: DIRECTOR /ADMINISTRATOR
Credential: BSN, RN
Phone: 707-263-7400